Daby, Kimball p -v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kimball Weston Daby Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 31,2013 66 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Lake Placid Street Address 187 McKinley St.
tp Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
G Medical Certifier Name Title
Christopher Hyson MD
Address
44 Church St.,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City, Town or Village Village of Lake Placid 1523
El Burial Date Cemetery or Crematory
Entombment November 1,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
t— Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human r ' s de ribed above as indicated.
Date Issued 11-01-2013 Registrar of Vital Statistics
(signature)
District Number 1523 Place Village of Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition nil 10 Place of Disposition ZAJ Atilt i—
W (address)
Cl)
pre (section) lot umber) (grave number)
Name of Sexton or Person in harge of Pr ises � ,' _ e,�,y�
Z (p ase print)
W
Signature Title CVLCJ Td t,
(over)
DOH-1555 (02/2004)